Provider Demographics
NPI:1588662803
Name:BOONSLICK MEDICAL GROUP INC
Entity Type:Organization
Organization Name:BOONSLICK MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BOONSLICK MED.GROUP INC
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:CUSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-916-8228
Mailing Address - Street 1:201 BJC SAINT PETERS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-3091
Mailing Address - Country:US
Mailing Address - Phone:636-916-8228
Mailing Address - Fax:636-946-5774
Practice Address - Street 1:201 BJC SAINT PETERS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-3091
Practice Address - Country:US
Practice Address - Phone:636-916-8228
Practice Address - Fax:636-946-5774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207N00000X, 207RG0100X, 207V00000X
MO430954457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990000198Medicare UPIN
990000198Medicare ID - Type Unspecified